2007 Oshodi - The Impact of Preoperative Education on Post-Operative Pain, Part 1

The impact of preoperative education on postoperative pain. Part 1 It has been made explicit in The NHS Plan (Department of Health, 2000) that patients need to be empowered with greater information to enable them to look after their own health. Gammon and Mulholland (1996) note that providing information to patients is important because of an increasing emphasis on self-care. The average stay in hospital is shorter because of surgical advancements (Gammon and Mulholland, 1996a). This success depends largely on comprehensive preparation of patients preoperatively (Dierking and Hockenberger, 1984), making information giving an important aspect of the process. Background French (1983) views anxiety as a biological defence mechanism operating in the face of impending, actual or imaginary danger. Preoperative patients usually express anxiety, which causes psychic disturbance. people perceive a threatening situation, their level of anxiety, coping styles and postoperative pain (Schwartz-Barcott et al, 1994; Krohne et al, 1996; Mitchell, 2000). Surgery, anxiety, preoperative education, and postoperative pain Hospitalization, even in patients who are not faced with the prospect of surgery, is known to cause anxiety and provokes a physiological stress response which impedes the healing process (Grieve, 2002). Bowers (1968) points out that the greater a person’s anxiety about pain, the greater the reactive pain. Reactive pain is a component of the total pain experience. One variable engendering anxiety about pain, and which therefore contributes to the degree of the reactive pain, is the perceived lack of control a person has over a present or potential stressor (Bowers, 1968). In an experimental study, Bowers (1968) found that the perception of little or no control over a painful stressor increases anxiety about it and that the anxiety thus generated, magnifies the pain perceived. This finding is supported by Breemhaar and Van de Borne (1991) who reported that a greater perceived control or an ability to influence an aversive stimulus is accompanied by a greater tolerance of that event. They identify that perceived control through the provision of education and support is able to reduce the stress experience in connection with surgery and to determine the manner in which stress is dealt with. They argue that increasing the perceived control of patients who tend to attribute little control to themselves is not accompanied by an improvement in adaptation to treatment and recovery. In the case of patients who attribute more control to themselves, measures to increase control appear to help them in developing expectations with regard to surgery. It has been suggested that several cognitive biases contribute to high anxiety: selective attention to threatening information, enhanced memory of threatening information, negative Abstract This article, the first of two parts, explores the general concept of preoperative education through a literature review. The relatively complex relationships between the ways people perceive a threatening situation, their levels of anxiety, coping styles and postoperative pain is explored. In dealing with these complex relationships, teaching strategies and forms of presentation of preoperative education are also discussed. The second part will examine the impact of preoperative education on postoperative anxiety, pain and recovery. This will be achieved by analysing the evidence available to provide a rigorous appraisal of the literature. Key words: Critical review n Preopertive education n Postoperative pain and recovery Titilayo O Oshodi is recent graduate, University of Worcester, Henwick Grove, Worcester Accepted for publication: May 2007 It may also contribute to problems during anaesthesia, which may include raised pre- and perioperative plasma adrenaline levels (Combley et al, 1991). If a patient is unduly anxious, physical recovery and well-being may be affected, prolonging hospital stay and increasing the cost of care (Hughes, 2002). Overview of preoperative education Lorig (2001) views patient education as any set of planned, educational activities designed to improve patients’ health behaviours, health status or both. Such activities are aimed at facilitating the patients’ knowledge base. Changes in knowledge may be necessary before a change in behaviours or health status can take place (Lorig, 2001). Caress (2003) notes that giving information, which is a part of the process of patient education, can be a passive process with no confirmation of whether the information is understood. Education, by contrast, implies a more active process, with confirmation that learning has taken place. Preoperative education informs patients of specific actions they can take to facilitate their own recoveries (Cupples, 1991). It has been demonstrated in the literature that a relatively complex relationship exists between the way that Titilayo O Oshodi 706 British Journal of Nursing, 2007, Vol 16, No 12 contributing to muscle breakdown, it was suggested that anxiety may serve to reduce surgical stress. How much information to give It is believed that the best type of anxiety- reducing intervention should support the patients’ coping styles while guiding him/ her from destructive behaviour (Krohne et al, 1996). Krohne et al defines two groups of people: the vigilant copers and the avoidant copers. Vigilant copers tend to use active coping mechanisms. They desire to know everything about their operations. On the other hand, avoidant copers tend to use passive coping mechanism: they desire only a minimal amount of information about their operation, just what is necessary and no more; while for the most part they prefer not to think about it. The two methods of coping are not exclusive but rather they represent the opposite ends of a continuum (Krohne et al, 1996). Preoperative preparation should always involve matching the amount of information provided with the patients’ preferred coping style (Mitchell, 2000). Preoperative education, decision making and consent Kriwanek et al (1998) reveal that patients can participate in surgical decisions only with complete understanding of all factors relevant to the proposed treatment. Examples of surgical decisions/care management include preferred options in certain situations, e.g. a Jehovah’s witness refusing a blood transfusion, living wills and advance directives, and how much the patient will like friends or relatives to know about their treatment. Through preoperative education, the capability of patients to take care of themselves improves through meeting their postoperative self-care needs at home (Gammon and Mulholland, 1996a,b). For example, information about appropriate behaviour after discharge (mobility, exercise, relaxation, appropriate diet or adequate pain control) will facilitate full recovery. In more recent years, there has been great emphasis on patient autonomy and the importance of informed consent (Garden et al, 1996). The issue relevant to informed consent is that of comprehension at the time the consent is obtained (Garden et al, 1996). Information should be tailored to suit the patients’ general level of comprehension, education and cultural background (Sowden et al, 2001). Patients can hardly be considered informed unless they have been told explicitly interpretations of ambiguous information, and a tendency to perceive a higher likelihood of negative events happening to one (Chen and Craske, 1998). Ng et al (2004) conducted an experimental study to analyse the effectiveness of preoperative information provision for anxiety reduction during dentoalveolar surgery in patients with high or low trait anxiety. In their study, Ng et al demonstrated that with the provision of preoperative information a person’s cognition can be changed and an event that is normally threatening can be rendered less so. Spielberger et al (1968) identify two types of anxieties - trait anxiety, which refers to the relatively stable individual differences in anxiety proneness, and state anxiety, which is a momentary subjective feeling of tension, apprehension, worry, nervousness and increased autonomic activities. Salmon (1993), however, argues that moderate levels of preoperative anxiety can help patients to prepare for surgery and reduce its stressfulness. On this basis, attempts to reduce anxiety are not necessarily in the patients’ best interest, but would amount to the ‘medicalization’ of a natural and emotional response which serves an important function. Salmon (1993) points out that for some time evidence has suggested a simpler relationship between preoperative anxiety and recovery, such that the lower the preoperative anxiety the better the postoperative state (e.g. less complaints of symptoms and shortening of postoperative stay). Salmon (1993) warns against relying on such indices of recovery but posits that more objective indices of surgical stress, such as measurements of postoperative endocrine and metabolic changes should be used as they display a conflicting situation. Some of these changes include increases in circulating cortisol, adrenaline and noradrenaline. In earlier experimental studies, Salmon et al (1988) measured preoperative state anxiety in patients undergoing major abdominal surgery. Plasma cortisol, adrenaline and noradrenaline were also measured on the preoperative day and at various times over the next 4 days. Higher preoperative anxiety predicted lower adrenaline levels postoperatively, and trait anxiety (Salmon et al, 1989) correlated negatively with cortisol levels postoperatively and adrenaline levels during surgery and postoperatively. Since, it has been noted that elevated circulating cortisol levels might impair immune function after surgery (Salmon et al, 1988); while adrenaline and noradrenaline are catabolic, about the risks involved in their surgery (Garden et al, 1996), as they also have the right to withhold consent if they are not happy about accepting these risks. If medical negligence is to be minimized (Waxman and Simons, 1999), and potential numbers of litigation reduced (Walker, 2002), it is vital that doctors ensure that the patient has carefully considered both the potential risks and the likely benefits. The patient as a learner Anderson et al (1998) define learning as knowledge, wisdom, or a skill acquired through systematic study or instruction. Lindeman (1988) points out that influencing human learning is a complex process affected by six major categories of variables: characteristics of the patient as a learner; characteristics of the nurse as a teacher; nurse-patient interaction as instructional strategy; characteristics of the target group; health care setting as learning environment; and the content. The process of teaching and learning is an interactive one with both the learner and the teacher having to be actively involved. Skills of educators The provider of health education requires several skills, which include understanding educational principles; sound, up-to- date, subject-specific knowledge; as well as resources available to support this information (Caress, 2003). Effective communication is a pivotal component of preoperative teaching (Caress, 2003; Sheehan, 2005), as it is necessary to achieve adequate understanding of the information provided (Mordiffi et al, 2003). Clark (1999) points out that the most important persuasive mode of communication takes place when there is personal interaction between the communicator and the recipient. Caress (2003) states that relevant educational principles include awareness of theories of learning, understanding of the needs of different learners and appreciation of the potential effects of ill-health and vulnerability of learners. Approaches to preoperative education Different approaches to delivering information have been investigated by many authors (Mavrias et al, 1990; Walker, 2002). The three main types of information which have been studied alone and in combination are: procedural, sensory and coping (Mavrias et al, 1990). It is generally believed that British Journal of Nursing, 2007, Vol 16, No 12 707 PAIN MANAGEMENT procedural information that focuses on the what, where and why of the surgery is best aimed at the less anxious populace; and that sensory information which focuses on any sensations and feelings to be expected throughout the surgical experience is best directed towards the more nervous patients (Walker, 2002). Furthermore, Wilson (1981) found a significant reduction in the self-rating of pain distress and intensity, increased reports of mobility and increased strength and energy in patients exposed to both sensory information and coping strategies. This conclusion was supported by Schwartz-Barcott et al’s (1994) findings, which reveal that sensory information provides patients with a clear image of the threat while relaxation training and postoperative exercise instructions gave them a set of action instructions to cope with the threat. Teaching strategies of preoperative education One-on-one vs group education One-on-one education is the most common type of patient education. It is what doctors, nurses and other health professionals do at the bedside or in the clinic (Lorig and Harris, 2001). In one-on-one education, there are four major considerations: time, knowing what to teach, knowing how to teach, and documenting what has been taught (Lorig and Harris, 2001). Everything said about one-to-one education is also true for group education, the difference is that the patient educator is going to do more than just lecture; he/she must have skills in group process (Lorig and Harris, 2001). There ahev been few studies in the recent past to compare outcome via one-to-one and group patient outcome. Lindeman (1972), in a comparative study of the effect of individual and group preoperative teaching on postoperative outcomes, found group teaching to be as effective as, and more efficient than individual teaching. According to Crabtree (1978), choosing between an individual or group teaching programme is termed an alternative choice problem. Crabtree conducted a cost-benefit analysis relating patient education to patient outcomes. The results showed that compared with those individually taught, group teaching required less nursing time. There was also a lower incidence of postoperative respiratory infection, making more efficient bed utilization possible. This conclusion is supported in a more recent quantitative study by Way et al (2003) who found that group teaching generated clear cost savings associated with its impact on length of stay. Structured vs unstructured education Structured teaching, which is based on course objectives and an outline, is used in some healthcare facilities, while unstructured teaching which leaves the teaching contents to the discretion of the teacher is used in others (Good-Reis and Pieper, 1990). Structured education can allow for preparation, identification of patient goals and development, and identification of educational resources; while unstructured education has the benefit of spontaneity and can be patient-focused, as it often occurs in response to an individuals’ questions (Caress, 2003). Due to the wide variations of sensory and procedural information that may be presented, essential contents could be missed (Good-Reis and Pieper, 1990). However, with most wards running on minimal staffing levels it would be advantageous to introduce preadmission teaching and orientation clinics to ensure that this procedure is conducted in a structured, comprehensive and unrushed manner (Walker, 2002). Lindeman and Van Aernam (1971) studied the effects of structured and unstructured preoperative teaching in a variety of surgical patients and reported a decrease in hospital stay and fewer postoperative complications in the group that received structured preoperative instructions. In similar studies, King and Tarsitano (1982) and Lookiland and Pool (1998) have also supported preoperative structured teaching. Forms of presentation Verbal education Verbal instruction is the cornerstone tool of preoperative teaching and whoever conveys information verbally must be cognizant of the recipients’ intellectual level and interest in acquiring the information (Whyte and Grant, 2005). Mordiffi et al (2003) investigated the preferred method of preoperative information delivery in 67 patients, and found that about 90% of the respondents preferred information to be delivered verbally. There are problems which need to be taken into account with verbal education. These include limited recall (Caress, 2003), language barriers, learning disabilities and cultural barriers (Whyte and Grant, 2005). For this reason, written educational materials are beneficial as a supplement to – not a replacement for – verbal education (Walker, 2002; Caress, 2003; Whyte and Grant, 2005). Supplementing oral instructions with written materials is an application of the education principle that information, which is repeated, will be retained and recalled more readily than information that is not repeated; written instructions can be referred to repeatedly by the patient (Lepczyk et al, 1990). Written materials Webber (1990) indicates that written materials are desired and appreciated by patients. Doak et al (2001) point out that many health professionals write for patients as if they were writing for scientific journals. The application of a readability formula will reveal that the material may not be understandable and needs to be reviewed (Doak et al, 2001). For information leaflets to be useful they must be up to date, accurate, relevant, and unambiguous, with short words and no jargon (Cooper, 1999). Garden et al (1996) highlight that if the provision of written material is done well before surgery, the patient is given time to seek an additional explanation. In a clinical setting where teaching time is limited, this type of information is useful (Estey et al, 1993). Caunt (1992) contends that it is of no significance which medium is used, as long as the information is presented clearly, thus giving the patient the advantage of predictability and control. The use of other media A variety of techniques are currently being used to educate patients. They include cassette tapes, video and information through the telephone. Whyte and Grant (2005) identify that much of this information is also available on the internet, but they caution that information obtained on the web can be highly biased, poorly referenced, and even self serving and promotional in nature but the reputable sources can provide valuable insights into treatment options available. Cost-effectiveness Webber (1990) notes that there is much interest in patient education as a means of reducing health care costs, but only a few studies have attempted to measure costs. Devine and Cook (1983) in a meta- analysis of the effect of psychoeducational interventions on length of hospital stay, using 49 studies, reveal that such interventions are cost effective as they reduce hospital stay by 1¼ days. Earlier discharge will encourage 708 British Journal of Nursing, 2007, Vol 16, No 12 PAIN MANAGEMENT and Viellion (1990) assert that timing is important in patient education, and point out that preoperative teaching is usually done the evening before surgery, when the patients’ anxiety could be so intense that learning is blocked. Intense anxiety and learning Anxiety is related to the level of arousal which at a high level may be detrimental to learning (Kiger, 1995). An extremely high level of arousal is associated with very high anxiety or even panics. In this case, the individual is likely to be distracted and unable to attend properly to any type of cognitive task (Payne and Walker, 2001). Memory for information is likely to be poor, or may focus only upon the most salient aspect to them. The best cognitive performance is obtained from someone whose adrenaline is flowing, who is alert and slightly anxious, and whose attention is focussed upon the task in hand and the content of what is being said. This indicates that the patients’ emotional state should be noted and time taken to listen to and calm someone who is highly anxious (Payne and Walker, 2001). It is thought to be beneficial to deliver information at times when anxiety is not elevated as patients might be more able to make rational choices about alternatives (Kent, 1996). Conclusion Having explored the concept of preoperative patient education, there appears to be a lot of arguments in the literature about its effectiveness but very few studies have sought to measure its impacts. The second part of this article will conduct a further literature search and a critical review through a rigorous methodology to evaluate the impact of preoperative patient education on postoperative recovery. BJN Acknowledgements The author would like to thank Louise Toner, Lecturer at the University of Worcester, for her help and inspiration. Bowers KS (1968) Pain, anxiety and perceived control. J Consult Clin Psychol 32(5): 596–602 Breemhaar B, van den Borne HW (1991) Effects of education and support for surgical patients: the role of perceived control. Patient Education and Counselling 18: 199–210 Caress AL (2003) Giving information to patients. Nurs Stand 17(43): 47–54 Caunt H (1992) Reducing the psychological impact of postoperative pain. Br J Nurs 1(1): 13–19 Chen E, Craske MG (1998) Risk perceptions and interpretations of ambiguity related to anxiety during a stressful event. Cognit Ther Res 22(2): 137–48 Clark A (1999) Changing attitudes through persuasive communication. Nurs Stand 13(30): 45–7 Combley M, Dunne JA, Sauders D (1991) stressful preoperative preparation procedures. Anaesthesia 46: 1019–22 cost-effectiveness and cost-containment; the rising cost of health care necessitates delivering care not just effectively, but economically as well (Way et al, 2003). Timing Hospitalization and surgery can be very stressful and anxiety provoking (Grieve, 2002). In the case of elective surgery, emotional reactions are exacerbated by having a long wait before the surgery is performed (Mavrias et al, 1990). Most studies have provided patients with information during the immediate preoperative period, neglecting the waiting period prior to hospitalization (Mavrias, 1990). It has been suggested that the time period between learning of the need for surgery and the actual surgery is a significant factor in determining preoperative anxiety level (Dumas and Johnson, 1972). The best time for providing preoperative information is still being argued (Walker, 2002). Cupples (1991) examined the effectiveness of preadmission preoperative education on patients having coronary artery bypass by comparing the preoperative knowledge levels and postoperative recoveries of patients who received a combination of preadmission and post admission education 5–14 days before admission (experimental group), with those of patients who received only routine post admission education on the day before surgery. The study clearly demonstrated that state anxiety levels were significantly lower 5–14 days before surgery than the night before surgery. The experimental group had significantly higher preoperative knowledge levels, more positive mood states, and more favourable physiologic recoveries than the control group. In contrast, Mavrias et al (1990) studied the effect of varying the timing of preoperative preparation on postoperative recovery by examining three groups of patients. 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Thorac Surg Clin 15: 195–201 KEY POINTS ■ The prospect of surgery can engender emotions, such as anxiety, fear of pain and incapacitation. ■ The perception of pain and anxiety is usually intensified when patients feel a lack of control over their situation. ■ Through preoperative education, anxiety is reduced, and patients are helped to gain control over their situation by getting them involved in their healing process, facilitating their own recoveries. ■ Patients who understand more about their condition will comply with their care needs. ■ Preoperative education contributes to early discharge which facilitates and encourages cost- effectiveness. 710 British Journal of Nursing, 2007, Vol 16, No 12